health systems, monitoring, evaluation, learning.

Asides

While i intend to write more about Packard’s new book (delightfully if uncomfortably subtitled, interventions into the lives of others) once i am through with it, a paragraph in the opening chapter seemed both so important and accurate as to merit sharing immediately — particularly given the lessons it may hold for the Universal Health Coverage (e.g.) movement. It is not that what Packard has to say here is necessarily new but rather that he sums it up in a neat, indicting list of trends, on which we would all do well to reflect:

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There have been remarkable continuities in how health interventions have been conceived and implemented over the past century… [that] have worked against the development of effective basic-health systems to address social determinants of health:

Health interventions have been largely developed outside the countries where the health problems exist, with few attempts to seriously incorporate local perspectives or community participation in the planning process…

Health planning has privileged approaches based on the application of biomedical technologies that prevent or eliminate health problems one at a time.

Little attention has been given to supporting the development of basic health services.

The planning of health interventions has often occurred in a crisis environment, in which there was an imperative to act fast. This mindset has privileged interventions that are simple, easy to implement, and have potential to quickly make a significant impact…

Global health interventions have been empowered by faith in the superioity of Western medical knowledge and technology…

Health has been linked to social and economic development — but this connection has focused primarily on how improvements in health can stimulate economic development, while ignoring the impact that social and economic developments can have on health. The social determinants of health have received little attention.

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Packard notes that these trends have faltered a few times, such as with the rise in interest in learning about the “social and economic causes of ill health” in the 1920s and 30s and in the Alma Ata / health for all movement at the end of the 1970s. We seem to think of ourselves as standing at a new trend-breaking moment. Hopefully we can do better.

agree that this is a potentially good sign about individual citizens being willing to engage in collective action – note also that many were most excited about lessened traffic, which is a good reason to think about inspiring collective action in ways that bring about both a public good and a private gain, allowing the pursuit of direct and indirect policy goals. my sense is there is still a long way to go in convincing people that the pollution is a problem and getting worse.

Researchers Michael Greenstone, Santosh Harish and Anant Sudarshan have some news for us. Hard data that shows that the Odd-Even plan reduced pollution by significant levels in Delhi. The headline: this study finds there was an 18% reduction in PM 2.5 due to the pilot during the hours that the rule was in effect. The effect size is truly staggering, and is quite unusual for studies that use such rigorous methodology to look at the impact of policy interventions.

Like this:

here’s a post that i’ve been half-meaning to write for awhile. for some time, i thought i had said all i needed to say in writing some words for her memorial.

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if the enormity of our – my – loss truly ever hits me, it will be through the small shared moments that can no longer be accumulated, even though skype tells me elif is only offline for now and gmail suggests that I may have meant to include her on my emails. with every absurd statement or mannerism over which we can’t exchange glances and snarky giggles or looks of outright disgust; with every annoyance or potentiality that can no longer be re-enacted and analysed over tea or wine; for every internet chat that no longer comes through filled with “hey lady”s “:-)”s and “;-)”s and exclamation marks at precisely the needed moment and in precisely the needed amount; and with every glass of wine i order at grafton’s knowing that she won’t be pedaling up soon in 4-inch heels to join me. maybe in this succession of elif-shaped voids I will begin to grasp what has stolen from me and from the world — through intolerance, the antithesis of all that elif believed.

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she was fearless in her approach to life, fiercely loyal in her friendships, focused in her work and infectious when she laughed. she *is* a fiercely loyal friend, appreciative and incisively honest, a yogi with a sharp tongue but a sharper wit, short-tempered but with a heart big enough to always make it OK, a perfectionist wrapped up in layers of clashing-but-considered clothes and scarves and flowers and hats. she is one of the finest partners-in-crime anyone could ask for.

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it’s been two years. but from time to time i still find myself etching a sentence or two in my mind. two 21st septembers have passed since the westgate mall shooting and i only managed to take a few sentences from my head and put them in a draft blog. i spilled little red wine out in remembrance on the appropriate dates and at a recent wedding that i know would have pleased her. a few weeks ago an (academic) article made me cry, resulting in some of the writing below.

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but i didn’t press ‘publish’ until watching the horrors of beirut and paris unfold across social media while sitting alone in a hotel in abuja, too connected and too separated and possibly with one too many heinekens. more dates. 9-11 and and 9-21 and 12/11 and 13/11 and 26/11. too many dates. ‘a calendar’ as the noun of accumulation of ‘terror.‘

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which i guess is when it hit me. it isn’t about the dates or the symbols or even really the cities. it’s about what is lost every day, for all of us, because of acts of terror. i don’t walk into a mall anywhere in the world without thinking about elif and wanting to walk out immediately. every time i hear someone use one of the words or phrases elif and i deemed as terrible, like “leaf peeping” (which people in new england insist on saying when they are going on a perfectly good outing to admire the autumn foliage) and “nibble” and “sequelae” (which particularly alarmed elif and she sketched once as a fearsome and carnivorous caterpillar-being) i want to write her immediately. i cannot. for the very specific reason of someone else’s hate and retribution. or statement.

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wikipedia tells me there is no agreed upon definition of terrorism but that pre-french revolution usages relate to a spreading mind-set of terror or dread, before questions about being state-sponsored or not cluttered up contemporary efforts at pinning down the idea. i’m actually not sure whether a visceral, sensory definition lies in the subtle sense of dread and suspicion of people that results from such acts or the small dead space in your brain, like an amputation, that still tries to light up when you think of someone you can no longer write. a hyper-sensitivity and a numbness.

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the best i can do now, or ever, is to remind the world what has been taken from them.

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elif and i bonded over the sort of humor that does not amuse everyone and downright offends some people. our first day of class together, in foundations of global health, the professor announced that some percentage of the world’s children would not enjoy their 5th birthdays. this is a euphemistic way of describing inequitable and horrifying under-5 mortality rates around the world, mostly from infectious disease, unhygienic surroundings, and poorly attended births. elif and i would not have been in a school of public health if we thought the underlying subject matter humorous. but the phrasing still tickled us. the birthdays wouldn’t be enjoyed because of insufficiently grand party hats? not enough party guests? somehow the subject of the joke became timmy and timmy and his failed birthday party were a recurring touchstone that got us through the two years till qualifying exams and three more years of school after that. and, hell, through elif (and ross) being on the verge of having their own child, traveling to nairobi from dar for just that purpose.

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and so it was a few weeks ago, on a random day, that i found myself sobbing when reading lant pritchett’s blog on the end of kinky development, in which he declares that “no one has ever held an ‘i am over $1.25 a day’ party.” which seems liked just the sort of party i would want to plan for timmy with elif.

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which, again, i guess, is the point, if there is one, which i am never sure there is. my grief isn’t eiffel-tower shaped or cedar-tree shaped or red or white or green or blue. it’s pink and teal and elif-shaped. it doesn’t come on a particular date. it comes any time of the day or night when i want to write “elif, you won’t believe…” and can only think ‘fuck you’ to people i have never met.

Like this:

earlier this week, a friend responded to this article on delhi’s pollution levels by reporting to facebook:

in the last week, 2 of my friends have moved back (one permanently & the other temporarily) to the states because of peak pollution levels. others are booking flights to leave the city for portions of the winter…

it seems that most of the adaptations we strive towards are restricted to creating healthy spaces for ourselves amongst the pollution that most of the city’s residents cannot escape.

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what she is saying, and is right, is that those of us that can and are staying in delhi are partially creating an air-istocracy. some of us are able to refine the very most public of goods — the air — for ourselves. a public good is by definition non-rivalrous and non-excludable. and yet we are working to make breathable air exclusive: in our flats, in our enclosed vehicles, in our office spaces, behind our masks.

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this needs to change, lest we become confined to these bubbles and delhi becomes even less friendly to pedestrians and cyclists and generally to taking a stroll or letting in a bit of fresh air through the windows.

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what i wrote on facebook, and i stand by at risk of being offensive, is this: in a considered and intentional, if provocative, turn of phrase to indicate violation or abuse without consent, delhi rapes my lungs on a daily basis.

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this intended to play on one of the major threats the outside world sees about living in delhi. the point is not to belittle violence against women experienced in delhi — which i have been merciful in not experiencing but which is a reality — or other forms of structural violence coped with on a daily basis. worrying about and living with these forms of violence wear people down to the point that they feel they can’t deal with something like the air. and so it goes undiscussed. but clean air is not ignorable. it is a form of violence and it needs to be addressed.

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to tackle a problem of the common or public good is a challenge anywhere; it is deeply bound up with ideas of citizenship and the social contract, of paying taxes and the role of government and the space for activism. it requires a government that can impose regulations to protect public goods and it requires citizens to expect and demand this of their government, though it is not a commodity that can be handed out. it is about far more than putting up ‘clean city, green city’ signs (as, incidentally, tackling violence against women is about more than hanging up coasters in taxis and autos declaring (in english) that the vehicle respects women).

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delhi and india, perhaps in particular, have a lot of work to do. i hope the world stays tuned and that india rises to the challenge. to close, i’ll allow someone else — mehtu in maximum city — to muse on public goods in india (a passage that, ironically, i first read in the much cleaner air of rishikesh):

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the flats in my building are spotlessly clean inside; they are swept and mopped every day, or twice every day. the public spaces – hallways, stairs, lobby, the building compound – are stained with betel spit; the ground is littered with congealed wet garbage, plastic bags, and dirt of human and animal origin. it is the same all over bombay, in rich and poor areas alike. this absence of a civic sense is something that everyone from the british to the hindu nationalists have drawn attention to, the national defect in the indian character (p. 138).

Like this:

there’s a lot of talk recently in various quarters about “tolerance” and who is and who is not — individually, nationally, etc. not all of it makes sense or rings true.

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it was nice, then, to come across this snippet from a letter from george washington written after the war for the independence of the united states, in vowell‘s new lafayette in the somewhat united states. as with all things of the era, it reflects ideals rather than being a perfect mirror of reality, but it is in keeping with a whole ethos of working to become less imperfect.vowell writes:

after the war, in 1790, newport’s synagogue would go on to inspire one of washington’s finer moments as a president and a person. responding to a letter from touro’s moses seixas, who asked the president if ratifying the bill of rights was, to paraphrase, good for jews.

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washington would send a letter addressed to the hebrew congregation at newport. the first amendment, he explained, exposed tolerance as a sham, because intolerance implies one superior group of people deigning to put up with their inferiors.

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‘it is now no more that toleration is spoken of as if it were the indulgence of one class of people that another enjoyed for the exercise of their inherent national rights,’ washington wrote. ‘for, happily, the government of the united states… gives to bigotry no sanction, to persecution no assistance.‘

the question of local leadership is not about the nationality of front-line actors; nor is it about donor agency staff not being involved in the process. it is about relationships in which aid money is not the primary motivator of what is done or a major influence on how it is done… the starting point is a genuine effort to seek out existing capacities, perceptions of problems and ideas about solutions, and to enter into some sort of relationship with leaders who are motivated to deploy these capabilities.